Oncology social workers move up and down the dial of intensity from crisis counseling to the mundane taxi voucher. While we may be rushed, we want to be especially attentive to our patients’ deeper, emotional needs and their strong desire to cope.
 

With so much research in psychosocial oncology, it would be difficult to find a conference that is not presenting evidence-based treatments to reduce distress and treat psychological problems in cancer patients. One of those treatments is Cognitive Behavior Therapy (CBT). It is one of the most effective, empirically supported, nonpharmacological interventions that has been shown to help cancer survivors cope with aversive aspects of their illness and its consequences.

A Few Highlights of CBT

CBT provides a structure for therapy and an understanding of the causes of depression and anxiety. Though the Rogerian therapeutic relationship is key, CBT provides shared exploration, learning and goal setting that empowers patients. The cognitive theory states that faulty thinking is at the core of depression and anxiety. This is reflected in a systematic bias in the way patients interpret experiences. Calling attention to this and exploring more reasonable explanations helps patients to change their thoughts, which effectively reduces symptoms.

The basic structure of CBT is the cognitive model that posits the way we perceive a situation is more closely related to one’s reaction to the situation than the situation itself. The therapist assists the patient to explore stressful events by identifying the situation, their automatic thoughts and reactions about the situation, which are further categorized by emotions, behaviors and physiological reactions. Automatic thoughts (ATs) are a window through which we discover the patient’s core beliefs about one’s self and the world, patterns of coping, cognitive distortions and unhelpful behaviors that can be modified in therapy. ATs are fleeting, often unidentified and normally unspoken thoughts that reflect a core belief about one’s self.

To help patients identify ATs, we ask, “What was going through your mind when you were so upset?” As the therapeutic relationship grows, we explore core beliefs such as, “I’m worthless, unlovable, or damaged.” These beliefs can be pervasive or transitory. Negative beliefs reinforce dysfunctional cognitions and behavior.

Socratic Questioning and Guided Discovery

To explore AT, we use Socratic questioning.

1. What is the evidence this is true (what makes you think this is true)? Is there any evidence this is not true?
2. Is there an alternative explanation?
3. What’s the worst thing that can happen? If it happens, how could you cope? What’s the best thing that can happen? What’s the most realistic outcome? When the automatic thought is “I will die,” we may assist the patient to explore their thoughts, fears and hopes about dying. We can ask, “What is the worst part of dying, what do you imagine about dying?”
4. What is the effect of me believing the automatic thought? What could be the effect of changing my thinking?
5. What would I tell (my friend, family member, coworker) if he or she were in the same situation?
6. What should I do?

Case Example

One of my young patients thought she caused her metastatic cervical cancer because she had sex at a young age (outside of marriage). We explored how much she believed this; she said 100 percent and that she had supporting evidence. We explored if there was any evidence that did not support this. We explored the cause and effect relationship of sex equals cervical cancer. I asked, “What about other young people who have sex? Do they all get cervical cancer?”

We looked for an alternative explanation. The painful reality was that the patient actually felt she had no control; there was no explanation for her cancer that turned her life upside down. We asked what was the effect of believing this. She thought it was making her more depressed. If she changed her thoughts, she thought she would be less depressed. Though she continued to believe this, she no longer believes it 100 percent and she decided to talk to her oncologist about her belief. She said she would have a more open mind about it.

Just as with my patient, many accept their thoughts uncritically. I had a patient tell me she never knew she did not have to believe her thoughts. She reasoned that these negative thoughts were telling her something true about herself.

Other Aspects of CBT

CBT is brief and collaborative. We ask the patient to tell us their goals for the session–what does he or she want to work on? And what we should talk about first? It emphasizes patients’ strengths and destigmatizes patients’ psychological problems. Patients generally respond very well to homework, examining thoughts and looking at their meaning.

The cognitive model helps us to understand anxiety and depression and provides a direction to help patients overcome them. The cognitive model of depression is that negative, distorted cognitions stemming from negative core beliefs are reinforced by distorted interpretations of events. We help patients to solve problems, choose better behaviors and respond differently to their negative thoughts. The cognitive model of anxiety is the overestimation of risk and underestimation of resources, which leads to anxiety. We assist patients by helping them better assess their risks, consider their internal and external resources, and promote building more resources.

There are numerous specific interventions that target depression and anxiety. For anxiety about treatments, imaginal and in-vivo exposure are very helpful in reducing anxiety. We evaluate unhelpful behavior so patients can learn to cope and adapt (think nutrition and exercise, reach out to increase social support).

Our patients are not inclined to fit nicely into our expectations. Remember that we move up and down the intensity dial not knowing what the needs may be. We must be flexible and let the patient lead. With more skills and training, we can increase our ability to respond to patient’s needs.

Oncology social work requires creativity, flexibility and risk-taking. I will never think, “I have this all figured out.” When a young mother who has metastatic disease tells me she is losing hope, I have no script. There is no formula or technique that provides confidence in that setting and there shouldn’t be. Even a better-informed, more skilled therapist hopefully will know where theory ends, and silence and mystery begin.

If you want to know more about CBT training, go to the Beck Institute at www.beckinstitute.org.